SHO Department Handbook Emergency Department, WRH

SHO Department Handbook

Emergency Department, WRH

Version Approved : Date Due for Review:

Contents

Duty rota

Study leave

Rotas/Sick leave/ Study leave/General introduction

Proforma/e-mail referral documents

ED computer system/confidentiality

Sharing information with the Police

Time critical medicine

End of life care

Medico-legal considerations / Note keeping

Medical reports

DVLA guidelines

Consent

Self-discharge

Discharge into Police custody


SHO'S HANDBOOK FOR ED 2019/20.

Welcome to the Emergency Department of Worcestershire Royal Hospital. This handbook is not

intended to be a textbook of Emergency Medicine, but should be used as a guide to departmental

policies, a reference source for useful information as well as a pointer to other sources of

information. If you take time to familiarise yourself with its contents, hopefully it will make your first

few days in ED a little less stressful. If you have any constructive comments to make - ideas for

additions to future editions, chapters which could be deleted, or corrections, please let me know.

Finally we hope you will find your time in ED at Worcester both pleasant and fulfilling.

THE DUTY ROTA

The duty rota is published several weeks ahead by the departmental secretary. Make sure any

swaps you arrange with your colleagues are documented on the copy at the nurses station, so that

we know who to contact should someone fail to turn up. Any swaps you do make should be made

with due consideration to not exceeding safe working hours.

Make sure that Michelle has a copy of contact addresses and telephone numbers for you should we

need to contact out of hours e.g. in the event of a major incident. We will also need a contact

address for you once you finish your 4/6 months, for medical reports etc.

Holidays must be booked 6 weeks in advance.

You may only book annual leave when you are allocated to annual leave or “floater” on the

rota. BOOK IT EARLY!

Meal breaks are normally about 20-30 minutes, but this is flexible depending on how busy the

department is. Please co-ordinate them with your colleagues so that only one of you is out of the

department at a time.

SICKNESS LEAVE: informing the consultant on call.

If you are too unwell to come in to work you must speak to the on call consultant as soon as

possible even if they are at home (switch board can transfer your call). When you return to work you

must speak to them again and have a back to work assessment.

STUDY LEAVE

At the start of your 4 months we will discuss your plans regarding further study for the 4 months,

and any appropriate study leave for personal study for examinations and courses. We will attempt

to get approval for any appropriate study leave which falls within Whitley Council regulations.


SENIOR COVER

There should always be a middle grade doctor available within the department. They will be able to

advise on most clinical problems. They should be called for advice on any patient in whom the

emergency management is unclear unless the patient is clearly appropriate for direct referral to

one of the in-patient teams. For the first month we expect you to discuss all referrals with a senior

doctor unless the referral is absolutely clear cut. They should also lead all trauma calls in the

department. There is also a consultant is also available at all times (see rota). We would normally

expect you to discuss the patient with the middle grade, before speaking to a consultant on call

except in exceptional circumstances. We can be reached via switchboard at any time for advice or

assistance. Rule number one is if you don't know ASK!

Patients return with the same problem should be discussed with a senior.

Support If you are having problems please speak to your clinical or educational supervisor or any

other senior member of the team.

Access to professional counselling:

Occupational Health Department 01905 760693 or 760694

Ex 34757 or 34752 [email protected]

RCN Counselling Service 0345 772 6100

BMA Counselling ` 0330 123 1245

Doctor Advisory Service 0330 123 1245

Blue Light Info Line 0300 303 5999

Consultant Review

When the following patients are in the department they should be reviewed by the consultant on the

shop floor if present::

1) Non traumatic chest pain patients who are being sent home 2) Children under 1 years of age who are being sent home 3) Patients who re-attend with the same condition 4) Any patient you have concerns about. 5) Patients 70years or more with abdominal pain


OPTIMISING SLEEP FOR NIGHT SHIFTS

Consider this a starting point for developing your own sleep strategy. BMJ – hyyp://bit.ly/BMJsleep

Day of First Night Shift – goal: minimise sleep debt

Sleep until you wake up (don’t set an alarm)

Avoid morning coffee

Take a 90 min nap between 14-18:00 During Night Shift – goal: Improve performance

Stay active

Eat lightly and to comfort

Build in checks during critical tasks to mitigate against reduced alertness performance Last Few Hours and Way Home

Avoid caffeine and nicotine

Try to avoid exposure to bright sunlight (sunglasses)

Consider public transport rather than driving Days between Night Shifts– goal: minimise sleep debt

Try to get to sleep as early as possible

Before trying sleep, avoid Bright lights, Screens, Alcohol

Sleep in a quiet darkened room

Accept that any sleep is better than none (even fragmented or shortened sleep episodes) and maximise sleep time

Resetting after Night Shifts Goal: re-establish normal sleep rhythm

Attempt 90 or 180 minute nap immediately following the shift

Go outside after waking

Aim to go to bed close to the normal time

Avoid daytime napping in the subsequent days.


Expectations of WRH Emergency Department SHOs

SHOs will endeavour to ensure all patients are seen and discharged / referred within 4hrs of

arrival in the emergency department (ED).

●Any patient without a plan at 2½ hours will be discussed with a senior doctor.

●Any patient at 3½ hours will be discussed with the ED co-ordinator & senior doctor.

●Any patient likely to breach 4hrs (eg. awaiting a particular investigation) and highly likely to go

home will be considered for the CDU, if a bed exists. If no bed exists on CDU or likely to become

available within the patient’s 4hr breach time then patient will be referred to an in-patient specialty

team.

●Patient First computer system will be kept up to date by the ED doctor, it is not the role of

the nursing team to complete the doctor’s computer work. CODE all your patients and FILE

all your results on ICE

●To aid communication ED SHOs will use the Staff Message function on Patient First to briefly

describe management plan status eg.”AWBR, CXR, if all OK, home”

●Before going on a break, SHOs will ensure none of their patients will ‘breach’ whilst they are away

and if this is a possibility then a plan will be made with the senior doctor and ED co-ordinator prior to

going on the break.


SHOs will escalate any concerns they have about patient management to a senior doctor at the

earliest possible time.

SHOs will prioritise patients who are clinically unstable NEWS>5, including patients with possible

(severe) Sepsis and those that the nursing staff have a clinical concern about and who are felt to

require an early rapid assessment.

SHOs will ensure that calls to the Resus Room are promptly answered by themselves or one of

their colleagues.

Prior to referral to an inpatient specialty the expectation is that all necessary immediate emergency

management will have been instituted.

All patients that are to be referred to an in-patient specialty team will be discussed with a senior

doctor before the referral takes place.

SHOs at the end of their shift will handover all their patients, including those they have admitted to

the CDU. Handover should be documented in the notes and on Patient First and include on-going

management plan. If formulating a management plan is not possible then the case should be

discussed with the senior doctor BEFORE handing over to another doctor, it is not acceptable to

handover a patient without a plan or one that essentially requires complete re-assessment by

another doctor.

Before discharging a patient who has not waited it is important to review their blood results and x-

rays.

SHOs will abide by the Trust’s policies on hand washing, bare below the elbow and disposal of

sharps and will wear the designated scrub uniform whilst on duty.

The ED card has been designed to try to ensure that all essential information is clearly recorded.

Please make sure that the child protection screen at the top of the page is completed, as well

as the tetanus status where appropriate. The diagnosis box, investigation box and disposal box

must also be properly completed.


WRH ED General Clinical Advice

● Always introduce yourself……………….”Hello my name is….”

● You need to answer 3 clinical questions:

Does the patient need resuscitation? Does the patient need pain relief or immediate antibiotics /fluid? Will the patient require further in patient care?

● Give analgesia early to patients who attend with pain, do this before launching into a full

examination and history.

● Try to formulate at least 3 differential diagnoses -symptoms (chest pain, collapse) are not

diagnoses.

● Try to write at least some of your notes at the trolley side

● Tell your patient your plan before you leave the consultation.

● Spend extra time with patients who irritate you.

● Always ask the patient what they want from being here and focus on what you can do to make

their day better.

● Almost no one wants to be a patient in an emergency department, however bad your day is going

the patient’s is probably worst.

● Emergency medicine is a team game – we will all help each each other and tasks cross job

descriptions frequently. In your time here you will check vital signs, push trolleys, get blankets, give

medication and countless other tasks that improve patient care.

● Keep busy – don’t have long periods of inactivity (this is what breaks are for)

● Be accurate in what you do – make your handwriting legible and your notes complete as well as

completing your own computer work – do not leave it to the nursing staff.

‘Forecasting’

Patients who understand why they are in the ED and the likely ‘things’ that will be happening during

their stay are more likely to less anxious, happy and rate the department as providing a quality

service. It is important that patients are kept informed during their stay in the ED, this includes:

Telling them why they are waiting

Likely length of any wait

Explaining likely journey eg. “ you have broken your hip…and will need surgery tomorrow…they’ll have you up and moving the very next day” or “we’ll have a proper look at you, get you (another) ECG, some blood tests and an X-ray and then asses what you are like on your feet…you can expect this to take a couple of hours”

Ensure patient has an opportunity to ask questions

Give the patient an advice leaflet where appropriate


List of Patient First Proformas and Drug Charts in the Additional Document section of

Patient First

PROFORMAS

ABG Result Sheet Asthma Adult Asthma Child Change Medication Cirrhosis decompensation Elderly Confusion Elderly Falls Elderly Frail Invasive Procedure Biers Block Invasive Procedure Chest Drain Invasive Procedure Central Line Invasive Procedure Femoral Nerve Block Invasive Procedure NG Tube Overdose Adult Overdose Child Procedural Sedation Form Spinal Cord Injury Abscond - Police Ambu Care Pulm Embolus Ambu Care Renal Colic Burns Management (major) COPD Bundle Discharge to Custody Discharge to NH RH ED Pneumonia bundle End Of Life Facial Injury Head Injury Adult Head Injury Child 0-16 Hip Trauma Flowchart Inoculation Proforma Intubation Checklist Kids Seizure Proforma Major Trauma Adult Major Trauma Paeds Neck Injury NIV Mental Health Matrix – Adult Mentla Health Matrix - Child PoP VTE RiskAssess Self-Discharge Severe Adult Sepsis Child Troponin RO Proforma

Primarily Nursing forms

s136 ED Monitor Form Mental Health Triage – Adult Mental Health Triage - Child Nurse Treatment Record Seizure Chart Stroke Triage Ward Transfer Checklist

Prescription Charts

Alcohol Withdrawal Parvolex

Miscellaneous

Gentamicin Assay Req

REFERRAL Documents

Once the form is completed you MUST

ask an ED receptionist to EMAIL it.

The form will only be emailed if you ask

the receptionist to do so.

Just leaving the completed form in the

notes WILL NOT get the form emailed.

Coroner Notify RIP TIA Referral Form SVT Referral Head Injury Therapy Service (HITS) First Fit Renal Colic Urinary Retention Chest Pain Clinic Referral Falls Clinic Referral email Ambu Care DVT Nurse Anaphylaxis Inoculation ED Pneumothorax SVT AF for cardiologist


ED COMPUTER SYSTEM/LETTERS TO GP's

Please note that the electronic patient record is just as much a medico-legal document as the written record and should be completed with as much care. You will be given tuition in use of the computer system when you arrive in ED. The computer is valuable for producing GP e-mails, to enable us to retrieve patient information without needing to get out the ED card, and for gathering statuary data for charter standards, payment by results etc. it is therefore essential that you note the following:-

1. Information should be put in “real-time” not put in retrospectively. (This is time consuming and

often inaccurate.) 2. Information should be the minimum required to sensibly fulfill the purpose of the computer i.e.

do not type in reams of unnecessary information which no-one will ever need but do make sure all treatments and investigations and preferably results are recorded.

3. If it is impossible to enter data real-time make sure all data is accurate when you do enter it. 4. IT IS THE DOCTORS RESPONSIBILITY TO FILE THE RESULTS ON ICE AND CODE THE

PATIENT ON PF. This generates a letter for the GP sent by e-mail. If you change patients regular mediacation complete a proforma and give it to the patient. ALL patients going back to any institution, eg care home, community hospital etc needs a proforma/discharge letter with the findings, diagnossi and plan

5. Make sure all data is entered for the correct patient.

CONFIDENTIALITY AND OTHER LEGAL CONSIDERATIONS Please refer to the full guidelines on Confidentiality and in “Legal Problems in Emergency Medicine”,

kept in the folder in Ms Johnsons office

Sharing information with the Police

We have a good relationship with the police and wish to foster this. However they are not always au fait with medical confidentiality and will sometimes request information that you are not at liberty to give them without the patient’s permission. Please note the following points:-

Do not give clinical information to the police, or anyone else without the permission of the patient. If

the police enquire about the condition of a patient from an RTA you may give them the name and

address of the patient and tell them whether they are seriously injured and/or likely to be admitted.

Do not release further details without speaking to the patient or a senior doctor. If the patient is going

home, tell them this and suggest that they speak to the patient themselves.

If they are requesting information about a patient who they believe has committed an offence, this

can only be divulged the crime is defined in the Police and Criminal Evidence Act as a serious

arrestable offence or is included in the provisions of the Road Traffic Act 1972, or if there is a serious

threat to public safety. Therefore you must refer them to the consultant on call.


DO NOT GIVE NOTES TO THE POLICE even if they have written consent. This should go through

the official process via the secretaries

The police should ask permission to breathalyse patients involved in a road traffic accident and you should agree to this if the patient is fit to do so. We have had problems in the past with giving clinical information to relatives against the wishes of

the patient. If there is any doubt whether the patient is likely to want the case discussed with anyone

other than themselves, check with the patient first.

Do not give information to employers without the express permission of the patient.

Be especially careful when giving information over the phone. When in doubt whether it is a

legitimate call from another professional body (for instance social services) take a phone number and

phone them back.

Refer all press enquiries to the press office in Trust headquarters. Out of hours refer callers to the

consultant on-call.

Confidentiality: Reporting gunshot and knife wounds Accessed 01.11.17: http://www.gmc-uk.org/guidance/ethical_guidance/30678.asp

Guidance

In our guidance Confidentiality: good practice in handling patient information we say: (taken out

numbers as they were random in this document-but probably from main document?)

Trust is an essential part of the doctor- patient relationship and confidentiality is central to this.

Patients may avoid seeking medical help, or may under-report symptoms, if they think that their

personal information will be disclosed by doctors without consent, or without the chance to have

some control over the timing or amount of information shared.

Doctors owe a duty of confidentiality to their patients, but they also have a wider duty to protect and

promote the health of patients and the public.

You should ask for a patient’s consent to disclose information for the protection of others unless it is

not safe or practicable to do so,1 or the information is required by law. You should consider any

reasons given for refusal.

If it is not practicable to seek consent, and in exceptional cases where a patient has refused consent,

disclosing personal information may be justified in the public interest if failure to do so may expose

others to a risk of death or serious harm. The benefits to an individual or to society of the disclosure

must outweigh both the patient’s and the public interest in keeping the information confidential.

If you consider that failure to disclose the information would leave individuals or society exposed to a

risk so serious that it outweighs the patient's and the public interest in maintaining confidentiality, you

should disclose relevant information promptly to an appropriate person or authority. You should

inform the patient before disclosing the information, if it is practicable and safe to do so, even if you

intend to disclose without their consent.


About this guidance

This explanatory guidance sets out how the principles in our guidance Confidentiality apply when a

patient presents with a gunshot wound or a knife wound that is not self-inflicted.

The principles in Confidentiality and this guidance apply to all violent injuries, but gunshot and knife

wounds raise issues that warrant special consideration, given the potential immediacy of risk to

others.

Reporting gunshot and knife wounds 4. The police are responsible for assessing the risk posed by

a member of the public who is armed with, and has used, a gun or knife in a violent attack. They

need to consider:

the risk of a further attack on the patient

the risk to staff, patients and visitors in the emergency department or hospital

the risk of another attack near to, or at, the site of the original incident.

The police also need statistical information about the number of gunshot and knife injuries, and when

and where they occur, to inform their own and their crime reduction partners’ operational and

strategic priorities.

For these reasons, the police should usually be informed whenever a person presents with a gunshot

wound. Even accidental shootings involving lawfully held guns raise serious issues for the police

about, for example, firearms licensing.2 The police should also usually be informed when a person

presents with a wound from an attack with a knife, blade or other sharp instrument.

The police should not usually be informed if a knife or blade injury appears to be accidental, or a

result of self-harm. There may also be other circumstances in which you consider that contacting the

police is not proportionate. For example, this might be the case if you consider that no one other than

the patient is at risk of harm, and that contacting the police might cause the patient harm or distress,

or might damage their trust in you or in doctors generally.

If you are in doubt about the cause of an injury, you should if possible consult an experienced

colleague.

Making the report

If you are responsible for the patient, you should make sure that the police are contacted where

appropriate, but you can delegate this task to another member of staff.

Personal information, such as the patient’s name and address, should not usually be disclosed in the

initial contact with the police. The police will respond even if the patient’s identity is not disclosed.

Make the care of the patient your first concern

When the police arrive, you should not allow them access to the patient if this will delay or hamper

treatment or compromise the patient’s recovery.


If the patient’s treatment and condition allow them to speak to the police, you or another member of

the healthcare team should ask the patient whether they are willing to do so. If they are not, you, the

rest of the healthcare team, and the police must abide by the patient’s decision.

Disclosing personal information without consent

If it is probable that a crime has been committed, the police will ask for more information. If

practicable, you should ask for the patient’s consent before disclosing personal information unless,

for example, doing so:

may put you or others at risk of serious harm

would be likely to undermine the purpose of the disclosure, by prejudicing the prevention,

detection or prosecution of a serious crime.

If the patient refuses consent or cannot give it (eg because they are unconscious), you can still

disclose information if it is required by law or if you believe disclosure is justified in the public interest.

Disclosures in the public interest may be justified when:

failure to disclose information may put someone other than the patient at risk of death or

serious harm (you should not usually disclose information against the wishes of an adult

patient who has capacity if they are the only person at risk of harm)3

disclosure is likely to help in the prevention, detection or prosecution of a serious crime.

If there is any doubt about whether disclosure without consent is justified, the decision should be

made by, or with the agreement of, the consultant in charge or the healthcare organisation’s Caldicott

or data guardian.

You must document in the patient’s record your reasons for disclosing information without consent

and any steps you have taken to seek their consent or inform them about the disclosure, or your

reasons for not doing so.

Unless it is not practicable or safe to do so, you should tell the patient about any disclosures that

have been made as soon as possible after the disclosure.

If there is no immediate reason for disclosing personal information in the public interest, no further

information should be given to the police. The police may seek an order from a judge or a warrant for

the disclosure of confidential information.4

Children and young people Any child or young person under age 18 years arriving with a gunshot

wound or a wound from an attack with a knife, blade or other sharp instrument is likely to raise child

protection concerns. Knife or blade injuries from domestic or occupational accidents, or from possible

self- harm, might also raise serious concerns about the safety of children and young people.


You should follow the advice in Protecting children and young people: The responsibilities of all

doctors whenever you are concerned that a child or young person has experienced, or is at risk of,

serious harm.

Time Critical Medications in the Emergency Department

It is not the role of the ED to write in-patient drug charts for patients who are being admitted. For

certain patient groups the timing of their medication is critical and it is important that they do miss a

dose whilst waiting in the ED. For the drug classes below the relevant medication should be

prescribed on the ED Cas Card to ensure patients do not miss a dose whilst they are in the ED (any

stay likely to greater than 2hrs or potentially the patient may miss a dose due to the timing of their

arrival).

Parkinson’s drugs

Anti-epileptics

Insulin

The ED pharmacists are an extremely valuable source of advice and are often able to confirm the

correct doses if there is any doubt.

End of Life Guidance

Discussions regarding patient treatment preferences should be communicated to GPs, care homes

and inpatient teams to enable continuity of care and end of life care planning.

If a patient is at the end of life, it may be appropriate to set a ceiling of treatment in the Emergency

Department

Establishing what the patient wants or if they lack capacity, what is in their best interests, should be

documented on a RESPECT form. A statement of planned active care should also be documented

including what care should and should not be provided.

Patients nearing the end of life should have a resuscitation decision made before leaving the

Emergency Department and this should be appropriately documented.

All DNACPR/RESPECT decisions should be discussed with the patient’s family and the patient

unless the patient is unable to understand the decision or unless it is thought the discussion will

cause physical or psychological harm to the patient, family or carers.

Opportunities for organ and tissue donation should be considered as a usual part of end of life care

in the Emergency Department. For full guidance google: RCEM End of life for adults

Patient First has an End of Life proforma located in the additional documents section. The

proforma is designed to help prompt decision making in patients who are known to be dying whilst in

the emergency department; it is accepted that the form will be completed at a particular point in time

and that not all suggested prompts will be appropriate for all patients and that the patient's condition

will change with time and decisions may be reviewed by ED team or other specialty teams caring the

patient during their stay in the emergency department. The reverse of the form has a useful list of


medications and doses that may be appropriate for patients at the end of their life; this is for

reference and there is no expectation that any or all will need prescribing.

The proforma is not mandatory for patients at the end of their life, however it is hoped that it will

provide some guidance and prompts regarding key questions / decision making for this group of

patients. It is important to remember that each patient is an individual and their care should be

dictated by what is best for them and their family and their particular circumstances. It is important

that care is individualised and compassionate and not merely reduced to a 'tick box' exercise on a

form. The palliative care specialist nurses can be reached on bleep 175.

MEDICO-LEGAL CONSIDERATIONS

NOTE KEEPING (please also refer to Worcestershire acute trust note keeping policy)

It is essential that you keep good records of each patient episode whilst you are in ED. Medico-legal

cases may arise years later when you know longer remember the case, and good note keeping

will be the only evidence that you made the correct management decisions. It is also essential for

continuity of care, as they may be seen with the same complaint by another doctor, or someone

else may need to write a report from your notes. However, you do not need to do a full medical

clerking, this is the responsibility of the admitting doctor.

You are expected to use the format as laid out in the ED card, and as a minimum the notes

should include the following:-

1. Date and time of initial examination.

2. Brief history to include mechanism and time of injury or incident.

3. Brief PMH and drug history (in all but the most minor cases)

4. Examination findings. This should include both positive and negative findings e.g. no scaphoid

tenderness in wrist injuries or no double vision in facial injuries.

5. All investigations done and the results (FILE on ICE). This should specify which X-rays and

bloods have been requested.

6. All procedures done. There should be evidence that appropriate verbal or written consent has

been obtained for the procedure, (see Section on consent and hospital policy) and that you have

warned the patient about possible complications.

7. All treatment prescribed. This should specify drug name, not just antibiotics or analgesia.

8. Discharge/ outcome - e.g. referred RMO. Include the name of any doctor that you refer the patient

to and time referred. Document follow-up arranged. Document the time at which you finish

dealing with the patient.


9. If you are handing the patient over to another doctor in A&E because you are going off duty, this

must also be recorded in the notes.

10. Legible signature and Name Stamp must be with each entry.

Whilst this appears all lot of information, it reality with most minor cases it can be completed very

quickly especially if you write the history whilst you are speaking to the patient.


Besides your clinical skills there are 5 things that protect you from medico-legal problems:

1. Communication

2. Documentation

3. Communication of documentation

4. Documentation of communication

5. Preservation of documentation

Each of these 5 are equally important.

MEDICAL REPORTS

Occasionally you will be asked to write medical reports/police statements. Always go through official channels i.e. check with the departmental secretary or a senior doctor if you are asked for a report. The police must have a signed document from the patient agreeing to your giving confidential medical information, before you provide a statement. This is a suitable format:-

I ................................... have been employed by Worcester Royal Infirmary NHS Trust as a Senior

House Officer in the Accident and Emergency department

since. ...............................

My qualifications are .................................................................... My General Medical Council

number is…..

I saw a patient who booked in as ........................................ (patients name) at ...................... (time) on ....................... (date) in the Accident and Emergency department at Worcester Royal Infirmary. He/she was brought to the department by ambulance*. (leave out if arrived by other means unless relevant) He/she alleged that he had been assaulted (or other mechanism of injury.) His/her injuries were:

1) ...............................

2) ...............................etc.

In my opinion these injuries were consistent with an assault (or other mechanism stated). He was

treated with ............................... and discharged home. A copy of the patients A&E card is

produced with this statement.

Try and write reports in lay-mans language not medical jargon. If possible describe the depth as well as the length of the wound and an approximate size of any bruises. If the wound required suturing, state the number of sutures used. Do not be tempted to guess at the cause of injury. Ask your clinical supervisor to review your first statement or if you have and questions.


This is a very abbreviated summary common conditions that we see in ED. If in doubt tell the patient to discuss it

further with their own GP.

DVLA guidelines Car drivers HGV

Neurological disorders

1st fit/solitary fit 6 months no driving then medical review 5 years fit free off medication required to

resume driving

Simple vaso-vagal No restriction. No restriction

TLOC with reliable prodrome while

standing

No restriction No restriction

TLOC with reliable prodrome while

sitting

4 weeks and only drive if cause found &

treated

3 months and only drive if cause found &

treated

TLOC without reliable prodrome or un

explained

Must not drive and notify DVLA.

If no cause found 6 months

Must not drive and notify DVLA.

If no cause found 12 months

Cough syncope Refuse/revoke 6 months and Refuse/revoke 5 years

TIA/CVA

Must not drive for at least one month. Multiple

TIAs 3 months asymptomatic Need to notify

DVLA if any unresolved neurological deficit

after 1 month

Refuse/revoke 1 year

Cardiac symptoms

Angina Must cease if symptoms at rest or at wheel Re-licensing permitted when 6 weeks pain

free and after exercise ECG

MI 4 weeks 6 weeks and exercise ECG

Arrythmia Driving must cease if the arrhythmia has caused or is likely to cause incapacity.

Driving may be permitted when underlying cause identified & controlled for at least 4/52

Driving must cease if the arrhythmia has caused or is likely to cause incapacity. . Driving may be permitted when underlying cause identified & controlled for at least 3/12

Diabetic problems

Frequent hypoglycaemic episodes likely to impair driving

Cease driving until satisfactory control re-established, with consultant/GP report

See full guidelines

Aortic Aneurysm If less than 6 cm can drive. If larger than 6.5 revoked if not treated

If less than 5.5 cm can drive but if greater

then revoked if not treated

Psychiatric disorders

Psychiatric disorders

Eg severe anxiety state or depression,

psychotic illness/hypomania

Driving must normally cease during the acute

illness. May normally resume after 3 months

after assessment. See full guidelines

See full guidelines

Persistent alcohol abuse 6 months license revocation until 6 months

controlled drinking or abstinence

1year license revocation until 6 months


Alcohol dependancy 1year license revocation until one year


3 years license revocation until 6 months

controlled drinking.

Liabllity to sudden attacks of

unprovoked disabling giddiness

Cease driving on diagnosis.

Driving wil be permitted when symptoms

controlled

Licence revoked.Must be 1 year symptom

free before re-application


CONSENT

The full hospital and departmental consent policy is kept in the departmental policy file in Ms Johnsons office. You should be fully conversant with this. Guidance is also available from the BMA in the “Report of the Consent Working Party”.

Consent must be voluntary, free from pressure and arise from a competence to decide.

Consent is required on every occasion the doctor wishes to instigate an examination or treatment or any other intervention except in emergencies or where the law prescribes otherwise.

Consent can be verbal, written or implied by acquiescence by a person who understands what will be undertaken. Acquiescence where a patient does not understand what the intervention entails or if there is an alternative option, is not “consent”.

Generally there is no legal requirement to obtain written consent but the consent form implies some discussion about the procedure has been undertaken. Discussion should be recorded separately in the patient’s notes.

In an emergency, where consent cannot be obtained, doctors may provide medical treatment that is immediately necessary to save life or avoid significant deterioration in the patient’s health. However advance statements and directives should be respected and may be legally binding.

Competent patients are entitled to refuse treatment even when doing so may result in permanent physical injury or death.

Legally no adult may give consent on behalf of another adult. Doctors may treat a patient who lacks capacity without consent in an emergency, providing it is necessary and in the patient’s best interests. If in doubt it may be necessary to involve an independent medical capacity advocate (IMCA) It is also good practice for the doctor to consult with relatives in assessing the patient’s best interests. Those discussions should be mindful of patient confidentiality.

Competent* minors can give consent to examination or treatment but it does not necessarily follow that they have the same right to refuse treatment.

Whether obtaining written or verbal consent the patient should be made fully aware of the risks and benefits of the procedure and any alternative treatments available. Information should include the following:

The purpose of the investigation or treatment.

Details of the diagnosis.

Uncertainties of the diagnosis.

Options for treatment, including the option not to treat.

Explanation of the likely benefits and probabilities for success for each option.

Known possible side effects.

A reminder that the patient can change their mind at any time. Please write in the notes that you have obtained verbal consent in the notes for any invasive procedure and use and document preform on Patient First Additional Document.. *Competent individuals should be able to: 1. Understand in simple language what the treatment is, its purpose and nature and why it is being

proposed. 2. the patient is able to retain the information long enough to make an effective decision 3. the patient is able to use or weigh the information to make a decision 4. the patient is able to communicate their decision by any means. The Mental Capacity Act 2005 see mental health section. (also trust policy?)


Self-discharge Having taken into consideration the guidance given above, the patient still wishes to take their own discharge they should be asked to complete the appropriate form. This has no legal status but indicates that appropriate discussion has taken place and that the patient’s capacity to refuse treatment has been assessed. This discussion should be documented in the patient’s notes. If the patient refuses to sign the form, then it would be advisable to ask another member of staff to witness and document the discussion with the patient. The patient should be advised when to seek further medical attention, and advised that they may return at any time for further treatment. If a patient does not wait to be seen, their x-rays and blood results should be reviewed and filed and if there are any concerns the senior doctor should be informed. Discharge from the Emergency Department into police custody

All patients discharged into the care of the police service must be discussed with a middle grade or more senior doctor.

All patients who are violent and/or aggressive must be assessed by a middle grade or more senior doctor to determine whether the patient is likely to be suffering from either a physical or mental illness and whether they have capacity (as defined by the Mental Capacity Act 2005) to be making decisions about their care. The department has a short form on Patient First additional Documents which needs to be

completed by a doctor when a patient is discharged from the emergency department into police

custody

Notes on completion of the form can be found on the reverse side. It is important to note that the

completed form must be signed by the patient before the form is given to the police officer.

Discharging back to Residential or Nursing Homes

Should have a completed proforma from Patient First Additional Documents so the cares are

aware of what has happened in hospital.

If their medication has been changed please complete the proforma from Patient First Additional

Documents.

Discharging Any Patient

Advice given to patients regarding medication changes should be clearly explained and

documented in the clinical record. There is a patient advice leaflet on Patient First for the purpose

of ensuring the patient is fully aware of any changes in medication that need to occur.

Please tell the patient what to do if they do not improve or get worse. Safety netting is very

important and we have dozens of ADVICE LEAFLET on PF which should be used.

It is good practice to ask patients if they have any questions prior to discharge.


Department Standard Operating Procedures

Please find below a list of Emergency Department SOPs-access these online to ensure the most

up to date information is being used.

Include link to main SOP page once its ready and published. Also should this include the other

main SOPs that have been written?

SHO Department Handbook Emergency Department, WRH

Documents

Transcript of SHO Department Handbook Emergency Department, WRH